Service Advocate III, FEP Claims Processing, QIP

Florida Blue Group; Jacksonville (FL); On-site; USD 25,000 - 39,000; Full time

Job summary

Florida Blue Group in Florida is seeking a Service Advocate III to review and adjudicate claims, determine pay or denial, and handle subrogation and related inquiries.

This role operates under guidance with some autonomy, uses computer systems, and seeks process improvements while supporting internal departments and members. The ideal candidate has 0-1 years of experience and a high school diploma or GED.

Qualifications

• High school diploma or GED required.
• 0-1 years related work experience.

Responsibilities

• Review and adjudicate high risk claims.
• Process credit listing functions, aged listings and held claims.
• Process adjustments by working with ambulance services, inpatient facility services and others.
• Determine whether to return, deny or pay claims following contract benefit and organizational processing guidelines.
• Perform additional research to develop claims; includes contacting providers or members.
• Provide customer service and education to plan members and providers by answering more complex questions regarding insurance claims and policies, resolving issues and ensuring customers understand the Company's products, services and processes.
• Calls are predominantly routine, but may require deviation from standard screens, scripts and procedures.
• Perform research to respond to inquiries and interpret policy provisions to determine most effective response.
• Use computerized systems for tracking, information gathering and troubleshooting.
• Actively seek, identify and implement process improvement opportunities.
• Perform other duties as assigned.

Education

High school diploma or GED

Job description

Start date: 11/16/2026

Training duration and hours: 11/16/20/2026 - 1/18/2027 Monday through Friday from 8:00 am to 4:30 pm EST.

Shift after training: Department hours 6:00 am- 6:00 pm, Monday through Friday, EST, an 8-hour shift will be determined based on shift bid.

Set pay rate for the role: $18.59

Job Summary

Reviews and adjudicates claims; determine whether to return, deny or pay claims following policies and procedures; process subrogation, workers' compensation and other claims where third party liability may exist; recover overpayments, and answer inquiries from other internal departments, insurance adjustors, attorneys and members. Representative Role Responsibilities: The work of a Service Advocate III is guided by instructions, established work routines and/or close supervision. Incumbents are given some latitude on deciding on how tasks and duties are completed based on changing work situations, work flow, etc. and supervisory approval. Incumbents perform semi-routine duties within established systems and procedures.

Essential Functions

• The essential functions listed represent the major duties of this role, additional duties may be assigned.
• Review and adjudicate high risk claims.
• Process credit listing functions, aged listings and held claims.
• Process adjustments by working with ambulance services, inpatient facility services and others.
• Determine whether to return, deny or pay claims following contract benefit and organizational processing guidelines.
• Perform additional research to develop claims; includes contacting providers or members.
• Provide customer service and education to plan members and providers by answering more complex questions regarding insurance claims and policies, resolving issues and ensuring customers understand the Company's products, services and processes.
• Calls are predominantly routine, but may require deviation from standard screens, scripts and procedures.
• Perform research to respond to inquiries and interpret policy provisions to determine most effective response.
• Use computerized systems for tracking, information gathering and troubleshooting.
• Actively seek, identify and implement process improvement opportunities.
• Perform other duties as assigned.

Required Experience

0-1 years related work experience.

No supervisory/management experience required

High school diploma or GED

General Physical Demands

Sedentary work: Exerting up to 10 pounds of force occasionally to move objects. Jobs are sedentary if traversing activities are required only occasionally.

What We Offer

As a Florida Blue employee, you will be at the heart of GuideWell's vision - to lead the nation in transforming health through compassionate, connected, and technology-enabled care that delivers personalized value and empowered living. To support your wellbeing, comprehensive benefits are offered. As an employee, you will have access to: Medical, dental, vision, life and global travel health insurance; Income protection benefits: life insurance, short- and long-term disability programs; Leave programs to support personal circumstances; Retirement Savings Plan including employer match; Paid time off, volunteer time off, 10 holidays and 2 well-being days; Additional voluntary benefits available; and; A comprehensive wellness program

Employee benefits are designed to align with federal and state employment laws. Benefits may vary based on the state in which work is performed. Benefits for intern, part-time and seasonal employees may differ.

To support your financial wellbeing, we offer competitive pay as well as opportunities for incentive or commission compensation. We also conduct regular annual reviews with pay for performance considerations for base pay increases.

Hourly Pay Range

$18 - $28

Hourly Hiring Rate

$18.59

Final pay will be determined with consideration of market competitiveness, internal equity, and the job-related knowledge, skills, training, and experience you bring.

We are an Equal Employment Opportunity employer committed to cultivating a work experience where everyone feels like they belong and can perform at their best in pursuit of our mission. All qualified applicants will receive consideration for employment.